A practice-related risk score (PRS): a DOPPS-derived aggregate quality index for haemodialysis facilities

Background. The Dialysis Outcomes and Practice Patterns Study (DOPPS) database was used to develop and validate a practice-related risk score (PRS) based on modifiable practices to help facilities assess potential areas for improving patient care. Methods. Relative risks (RRs) from a multivariable Cox mortality model, based on observational haemodialysis (HD) patient data from DOPPS I (1996-2001, seven countries), were used. The four practices were the percent of patients with Kt/V >= 1.2, haemoglobin >= 11 g/dl (110 g/l), albumin >= 4.0 g/dl (40g/l) and catheter use, and were significantly related to mortality when modelled together. DOPPS II data (2002-2004, 12 countries) were used to evaluate the relationship between PRS and mortality risk using Cox regression. Results. For facilities in DOPPS I and II, changes in PRS over time were significantly correlated with changes in the standardized mortality ratio (SMR). The PRS ranged from 1.0 to 2.1. Overall, the adjusted RR of death was 1.05 per 0.1 points higher PRS (P < 0.0001). For facilities in both DOPPS I and II (N = 119), a 0.2 decrease in PRS was associated with a 0.19 decrease in SMR (P = 0.005). On average, facilities that improved PRS practices showed significantly reduced mortality over the same time frame. Conclusions. The PRS assesses modifiable HD practices that are linked to improved patient survival. Further refinements might lead to improvements in the PRS and will address regional variations in the PRS/mortality relationship

Correcting 100 years of misunderstanding: electric fields in superconductors, hole superconductivity, and the Meissner effect

From the outset of superconductivity research it was assumed that no electrostatic fields could exist inside superconductors, and this assumption was incorporated into conventional London electrodynamics. Yet the London brothers themselves initially (in 1935) had proposed an electrodynamic theory of superconductors that allowed for static electric fields in their interior, which they unfortunately discarded a year later. I argue that the Meissner effect in superconductors necessitates the existence of an electrostatic field in their interior, originating in the expulsion of negative charge from the interior to the surface when a metal becomes superconducting. The theory of hole superconductivity predicts this physics, and associated with it a macroscopic spin current in the ground state of superconductors ("Spin Meissner effect"), qualitatively different from what is predicted by conventional BCS-London theory. A new London-like electrodynamic description of superconductors is proposed to describe this physics. Within this theory superconductivity is driven by lowering of quantum kinetic energy, the fact that the Coulomb repulsion strongly depends on the character of the charge carriers, namely whether electron- or hole-like, and the spin-orbit interaction. The electron-phonon interaction does not play a significant role, yet the existence of an isotope effect in many superconductors is easily understood. In the strong coupling regime the theory appears to favor local charge inhomogeneity. The theory is proposed to apply to all superconducting materials, from the elements to the high $T_c$ cuprates and pnictides, is highly falsifiable, and explains a wide variety of experimental observations.Comment: Proceedings of the conference "Quantum phenomena in complex matter 2011 - Stripes 2011", Rome, 10 July -16 July 2011, to be published in J. Supercond. Nov. Mag

Condensate and superfluid fractions for varying interactions and temperature

A system with Bose-Einstein condensate is considered in the frame of the self-consistent mean-field approximation, which is conserving, gapless, and applicable for arbitrary interaction strengths and temperatures. The main attention is paid to the thorough analysis of the condensate and superfluid fractions in a wide region of interaction strengths and for all temperatures between zero and the critical point T_c. The normal and anomalous averages are shown to be of the same order for almost all interactions and temperatures, except the close vicinity of T_c. But even in the vicinity of the critical temperature, the anomalous average cannot be neglected, since only in the presence of the latter the phase transition at T_c becomes of second order, as it should be. Increasing temperature influences the condensate and superfluid fractions in a similar way, by diminishing them. But their behavior with respect to the interaction strength is very different. For all temperatures, the superfluid fraction is larger than the condensate fraction. These coincide only at T_c or under zero interactions. For asymptotically strong interactions, the condensate is almost completely depleted, even at low temperatures, while the superfluid fraction can be close to one.Comment: Latex file, 22 pages, 5 figure

Kinetic energy driven superconductivity and superfluidity

The theory of hole superconductivity proposes that superconductivity is driven by lowering of quantum kinetic energy and is associated with expansion of electronic orbits and expulsion of negative charge from the interior to the surface of superconductors and beyond. This physics provides a dynamical explanation of the Meissner effect. Here we propose that similar physics takes place in superfluid helium 4. Experimental manifestations of this physics in $^4He$ are the negative thermal expansion of $^4He$ below the $\lambda$ point and the "Onnes effect", the fact that superfluid helium will creep up the walls of the container and escape to the exterior. The Onnes effect and the Meissner effect are proposed to originate in macroscopic zero point rotational motion of the superfluids. It is proposed that this physics indicates a fundamental inadequacy of conventional quantum mechanics

A systematic review of patient and health system characteristics associated with late referral in chronic kidney disease

<p>Abstract</p> <p>Background</p> <p>To identify patient and health system characteristics associated with late referral of patients with chronic kidney disease to nephrologists.</p> <p>Methods</p> <p>MEDLINE, CENTRAL, and CINAHL were searched using the appropriate MESH terms in March 2007. Two reviewers individually and in duplicate reviewed the abstracts of 256 articles and selected 18 observational studies for inclusion. The reasons for late referral were categorized into patient or health system characteristics. Data extraction and content appraisal were done using a prespecified protocol.</p> <p>Results</p> <p>Older age, the existence of multiple comorbidities, race other than Caucasian, lack of insurance, lower socioeconomic status and educational levels were patient characteristics associated with late referral of patients with chronic kidney disease. Lack of referring physician knowledge about the appropriate timing of referral, absence of communication between referring physicians and nephrologists, and dialysis care delivered at tertiary medical centers were health system characteristics associated with late referral of patients with chronic kidney disease. Most studies identified multiple factors associated with late referral, although the relative importance and the combined effect of these factors were not systematically evaluated.</p> <p>Conclusion</p> <p>A combination of patient and health system characteristics is associated with late referral of patients with chronic kidney disease. Overall, being older, belonging to a minority group, being less educated, being uninsured, suffering from multiple comorbidities, and the lack of communication between primary care physicians and nephrologists contribute to late referral of patients with chronic kidney disease. Both primary care physicians and nephrologists need to engage in multisectoral collaborative efforts that ensure patient education and enhance physician awareness to improve the care of patients with chronic kidney disease.</p

Global and exponential attractors for a Ginzburg-Landau model of superfluidity

The long-time behavior of the solutions for a non-isothermal model in superfluidity is investigated. The model describes the transition between the normal and the superfluid phase in liquid 4He by means of a non-linear differential system, where the concentration of the superfluid phase satisfies a non-isothermal Ginzburg-Landau equation. This system, which turns out to be consistent with thermodynamical principles and whose well-posedness has been recently proved, has been shown to admit a Lyapunov functional. This allows to prove existence of the global attractor which consists of the unstable manifold of the stationary solutions. Finally, by exploiting recent techniques of semigroups theory, we prove the existence of an exponential attractor of finite fractal dimension which contains the global attractor.Comment: 39 page

What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions?

BACKGROUND: Priority setting, also known as rationing or resource allocation, occurs at all levels of every health care system. Daniels and Sabin have proposed a framework for priority setting in health care institutions called 'accountability for reasonableness', which links priority setting to theories of democratic deliberation. Fairness is a key goal of priority setting. According to 'accountability for reasonableness', health care institutions engaged in priority setting have a claim to fairness if they satisfy four conditions of relevance, publicity, appeals/revision, and enforcement. This is the first study which has surveyed the views of hospital decision makers throughout an entire health system about the fairness of priority setting in their institutions. The purpose of this study is to elicit hospital decision-makers' self-report of the fairness of priority setting in their hospitals using an explicit conceptual framework, 'accountability for reasonableness'. METHODS: 160 Ontario hospital Chief Executive Officers, or their designates, were asked to complete a survey questionnaire concerning priority setting in their publicly funded institutions. Eight-six Ontario hospitals completed this survey, for a response rate of 54%. Six close-ended rating scale questions (e.g. Overall, how fair is priority setting at your hospital?), and 3 open-ended questions (e.g. What do you see as the goal(s) of priority setting in your hospital?) were used. RESULTS: Overall, 60.7% of respondents indicated their hospitals' priority setting was fair. With respect to the 'accountability for reasonableness' conditions, respondents indicated their hospitals performed best for the relevance (75.0%) condition, followed by appeals/revision (56.6%), publicity (56.0%), and enforcement (39.5%). CONCLUSIONS: For the first time hospital Chief Executive Officers within an entire health system were surveyed about the fairness of priority setting practices in their institutions using the conceptual framework 'accountability for reasonableness'. Although many hospital CEOs felt that their priority setting was fair, ample room for improvement was noted, especially for the enforcement condition

Association of dialysis facility-level hemoglobin measurement and erythropoiesis-stimulating agent dose adjustment frequencies with dialysis facility-level hemoglobin variation: a retrospective analysis

<p>Abstract</p> <p>Background</p> <p>A key goal of anemia management in dialysis patients is to maintain patients' hemoglobin (Hb) levels consistently within a target range. Our aim in this study was to assess the association of facility-level practice patterns representing Hb measurement and erythropoiesis-stimulating agent (ESA) dose adjustment frequencies with facility-level Hb variation.</p> <p>Methods</p> <p>This was a retrospective observational database analysis of patients in dialysis facilities affiliated with large dialysis organizations as of July 01, 2006, covering a follow-up period from July 01, 2006 to June 30, 2009. A total of 2,763 facilities representing 436,442 unique patients were included. The predictors evaluated were facility-level Hb measurement and ESA dose adjustment frequencies, and the outcome measured was facility-level Hb variation.</p> <p>Results</p> <p>First to 99th percentile ranges for facility-level Hb measurement and ESA dose adjustment frequencies were approximately once per month to once per week and approximately once per 3 months to once per 3 weeks, respectively. Facility-level Hb measurement and ESA dose adjustment frequencies were inversely associated with Hb variation. Modeling results suggested that a more frequent Hb measurement (once per week rather than once per month) was associated with approximately 7% to 9% and 6% to 8% gains in the proportion of patients with Hb levels within a ±1 and ±2 g/dL range around the mean, respectively. Similarly, more frequent ESA dose adjustment (once per 2 weeks rather than once per 3 months) was associated with approximately 6% to 9% and 5% to 7% gains in the proportion of patients in these respective Hb ranges.</p> <p>Conclusions</p> <p>Frequent Hb measurements and timely ESA dose adjustments in dialysis patients are associated with lower facility-level Hb variation and an increase in proportion of patients within ±1 and ±2 g/dL ranges around the facility-level Hb mean.</p

Reimbursement and economic factors influencing dialysis modality choice around the world

The worldwide incidence of kidney failure is on the rise and treatment is costly; thus, the global burden of illness is growing. Kidney failure patients require either a kidney transplant or dialysis to maintain life. This review focuses on the economics of dialysis. Alternative dialysis modalities are haemodialysis (HD) and peritoneal dialysis (PD). Important economic factors influencing dialysis modality selection include financing, reimbursement and resource availability. In general, where there is little or no facility or physician reimbursement or payment for PD, the share of PD is very low. Regarding resource availability, when centre HD capacity is high, there is an incentive to use that capacity rather than place patients on home dialysis. In certain countries, there is interest in revising the reimbursement structure to favour home-based therapies, including PD and home HD. Modality selection is influenced by employment status, with an association between being employed and PD as the modality choice. Cost drivers differ for PD and HD. PD is driven mainly by variable costs such as solutions and tubing, while HD is driven mainly by fixed costs of facility space and staff. Many cost comparisons of dialysis modalities have been conducted. A key factor to consider in reviewing cost comparisons is the perspective of the analysis because different costs are relevant for different perspectives. In developed countries, HD is generally more expensive than PD to the payer. Additional research is needed in the developing world before conclusive statements may be made regarding the relative costs of HD and PD

Exploring the impact of a decision support intervention on vascular access decisions in chronic hemodialysis patients: study protocol

<p>Abstract</p> <p>Background</p> <p>In patients with Stage 5 Chronic Kidney Disease who require renal replacement therapy a major decision concerns modality choice. However, many patients defer the decision about modality choice or they have an urgent or emergent need of RRT, which results in them starting hemodialysis with a Central Venous Catheter. Thereafter, efforts to help patients make more timely decisions about access choices utilizing education and resource allocation strategies met with limited success resulting in a high prevalent CVC use in Canada. Providing decision support tailored to meet patients' decision making needs may improve this situation. The Registered Nurses Association of Ontario has developed a clinical practice guideline to guide decision support for adults living with Chronic Kidney Disease <it>(Decision Support for Adults with Chronic Kidney Disease</it>.) The purpose of this study is to determine the impact of implementing selected recommendations this guideline on priority provincial targets for hemodialysis access in patients with Stage 5 CKD who currently use Central Venous Catheters for vascular access.</p> <p>Methods/Design</p> <p>A non-experimental intervention study with repeated measures will be conducted at St. Michaels Hospital in Toronto, Canada. Decisional conflict about dialysis access choice will be measured using the validated SURE tool, an instrument used to identify decisional conflict. Thereafter a tailored decision support intervention will be implemented. Decisional conflict will be re-measured and compared with baseline scores. Patients and staff will be interviewed to gain an understanding of how useful this intervention was for them and whether it would be feasible to implement more widely. Quantitative data will be analyzed using descriptive and inferential statistics. Statistical significance of difference between means over time for aggregated SURE scores (pre/post) will be assessed using a paired t-test. Qualitative analysis with content coding and identification of themes will be conducted for the focus group and patient interview data.</p> <p>Discussion</p> <p>Coupling the SURE tool with a decision support system structured so that a positive test result triggers providers to help patients through the decision-making process and/or refer patients to appropriate resources could benefit patients and ensure they have the opportunity to make informed HD access choices.</p